Moving Beyond the Medicare Orthodoxy

Why is it that Canada’s two main political parties have virtually identical positions on medicare, while the public is now looking for new options?

Successful political movements – those that capture the imagination of their countrymen – are rare without intellectual proponents. Think of Marx and Marxism, Churchill and Axis defiance, Lévesque and Quebec separatism.

But there is no easily identifiable figure behind medicare. That this 1960s idea, copied in its entirety from another country, would grow to become in many eyes the defining characteristic of nationhood is a curiosity.

But if there is no single individual, there is orthodoxy. Medicare proponents do not quote from a Das Kapital-like volume, but they do have a common argument. Indeed, there is a nearly uniform opinion among health economists, policy analysts and administrators. It runs something like this: Canada has the best health-care system in the world. All problems can be rectified. To do this, look to government intervention, either with greater public spending or with greater public regulation and management. And beware: any proposed change to this system based on individual choice or competition would be an “Americanization,” and thus disastrous.

The logic is shaky on several accounts, but the profound acceptance of that orthodoxy, call it the Majority Opinion, is striking. Consider the recent federal election. Much distinguishes the two main political parties: issues of taxation, government intervention in the economy, abortion – but not health care.

Health care was the key issue of the campaign, observed many pundits. But, if it was, exactly what sort of debate was there? The Liberals believe in more funding for medicare. So does the Canadian Alliance (and, for that matter, so, too, do the other three parties). The Liberals like home care, health information and believe that high-tech equipment is lacking in the present system. Stockwell Day’s party emphasizes innovation within the context of the Canada Health Act, which means home care. The Canadian Alliance also favours higher funding for medicare, thus helping to support more high-tech equipment and health information systems. When we get to the contentious issues, let me know.

In conversation with a staffer in Allan Rock’s office, I raised that point. Of course, she was appalled – simply, she suggested, look at the Liberal and Canadian Alliance positions on Alberta’s Bill 11. But then, how do they differ? I mean, really differ. In an age of word parsing (“depends on what the definition of the word ‘is’ is”), we can find some differences. The Canadian Alliance view provincial experimentation like Bill 11 to be useful and compatible with the Canada Health Act (CHA). The Liberals view Bill 11 as a mistake, violating the spirit of the CHA. What will they do about it?
Absolutely nothing.

In fact, the only surprise during the campaign came when the Prime Minister announced that private MRI facilities undermine the public nature of Canadian health care. If re-elected, Jean Chrétien promised to abolish them. The announcement directly contradicted the public statement made by the minister of health the day before. Indeed, it ran against a half-decade of Health Canada policy that did nothing to discourage the establishment of such facilities. There was also an added political embarrassment – many of Canada’s private MRIs are owned by a Liberal fundraiser, a Calgary businessman. Just days before the anti-private MRI comment, Chrétien had attended a fundraiser hosted by this Calgarian.

But as the Canadian media dwelled on the policy reversal, many forgot the position taken by Day. The Leader of the Opposition, running on a platform that would slash taxes, end regional subsidies, and eliminate federal job creation programs, had basically proposed a Chrétien-style abolishment of the facilities during an Ontario campaign stop-two weeks earlier. According to Day, the CHA should be expanded to cover all MRIs.

Welcome to the topsy-turvy world of health-care politics.

There is, of course, a curious development in all this. It’s not clear that Canadians are on side. The Majority Opinion holds sway with our polity, not necessarily our public. Certainly, despite the reassuring voice of the experts, Canadians wonder about the quality of care. Early in 2000, Angus Reid (now Ipsos-Reid) surveyed Canadians on the state of medicare: 78% of Canadians suggest the system is “in crisis.”

More surprising still, however, is polling data on the “unthinkable” changes to medicare. In a Maclean’s-Global Television poll of 1,400 Canadians, roughly half (47%) support a two-tiered system. Support for user fees was even higher: 54% of respondents favour the idea.

Interestingly, regional difference has little impact on opinion. Atlantic Canadians endorsed co-payment with almost as much zeal as British Columbians (52% and 55%, respectively). Saskatchewan, the great hub of prairie socialism, has the highest level of support for user fees, at 69%. Only in Ontario did support fall below a majority, but just barely – 48% accepted moderate user fees.

Approval for private insurance was more tempered, but still strong. In certain provinces, British Columbia and Quebec, a clear majority favoured the notion.

The Majority Opinion, it turns out, is a minority opinion. Canadian experts seem to sense the change in mood, as well. Gone is the rhetoric about Canadians opposing user fees or private insurance. Instead, the experts speak of our “values” and policies that support those values.

Public health care – like every area of public policy – ought to be undergoing constant experimentation and innovation. Instead, we have a system that is ossified. One of the benefits of a federal system such as ours (federal funding but provincial administration) is the ability of individual jurisdictions to test new ideas. Canada should be witnessing 10 laboratories of health-care experimentation. We have instead uniform stagnation.

That may seem like a harsh indictment. But consider how modest the present batch of reforms is. The most radical legislation is in Alberta, where Bill 11 proposes to allow regional health boards to contract out surgeries requiring overnight stays. No other province even dares contemplate this bold move. How does such a move compare to the German initiative to privatize 90% of public hospitals or the British effort to forge public-private management in new hospitals?

User fees? No province would dare. Even in Sweden, they have user fees now. Wander into the family doctor’s office there with a sore throat or an upset stomach and expect to pay $20. Private insurance? Every Western country allows its citizens to opt out – except Canada. In some nations, tax breaks are offered for medical insurance purchase. More private insurance, the thinking goes, less demand on the public purse.

Nationalism makes for good rhetoric but mediocre public policy. Despite the urgings of our politicians, Canadians are reaching this conclusion. And that has all the makings of a new movement.

(This article originally appeared in the January 2001 issue of The Medical Post.)